**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of two facility Self-Reported Incidents (SRIs), associated investigations and the facility abuse policy and procedure, interviews with staff, Medical Director #535, Certified Nurse Practitioner (CNP) #506 and #611, the facility failed to ensure Resident #12 and Resident #123, assessed as cognitively impaired, were free from sexual abuse by Resident #13. This resulted in Immediate Jeopardy and the potential for serious harm on [DATE] at 6:30 A.M. when Resident #13 was observed in Resident #123's room with his hands inside Resident #123's underwear. The Immediate Jeopardy remained ongoing, on [DATE] at 8:15 P.M. when Resident #13 was observed with his arm/hand down the front of Resident #12's blouse. There was no evidence, following either incident, the facility immediately assessed Resident #123 or Resident #12 and no evidence the facility implemented interventions to prevent further incidents of sexual abuse by Resident #13. This affected two residents and had the potential to affect 21 additional cognitively impaired female residents (Residents #1, #4, #8, #9, #15, #19, #22, #26, #28, #32, #33, #34, #37, #38, #41, #45, #46, #50, #56, #59 and #60) identified by the facility to be at risk. The facility census was 70. On [DATE] at 4:24 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when Resident #13 was observed with his hands inside Resident #123's underwear making sexual motions. The Immediate Jeopardy continued on [DATE] when Resident #13 was observed with his arm down the front of Resident #12's blouse. The facility failed to thoroughly investigate either incident of sexual abuse and failed to timely develop and implement an individualized plan for Resident #13 to address sexually inappropriate behaviors and prevent additional incidents of sexual abuse. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE], the DON initiated education for all staff members on sexual abuse, safety of residents during a potentially abusive situation, resident rights, how to report suspected abuse and who to report it to. The training was overseen by the Administrator. As of [DATE] at 8:40 A.M., 174 of 179 staff members were in-serviced. The five staff members who had not received the education were on leave and a plan for these employees to receive the education prior to returning to work was in place. • On [DATE], the facility implemented a plan for behavior monitoring to be completed each shift per the charge nurse for Resident #13. The charge nurse would audit for verbal or physical sexual advances, initiate interventions including redirection to supervised activities or to his room, one-to-one supervision or medication administration to deter or stop behavior and determine the effectiveness. This would remain ongoing until Resident #13 had a significant change in condition which the facility had defined as a functional decline related to Parkinson's disease. This will be overseen by the Quality Assurance (QA) committee quarterly. • On [DATE] Resident #13's plan of care was updated to reflect the addition of Lexapro for sexually inappropriate behaviors and to reflect his past incidents of sexual abuse with female residents. • On [DATE] the facility Abuse policy and procedure was updated to include definitions of potential sources of abuse including resident to resident, staff to resident, family member to resident, and visitor to resident. • On [DATE] a physician's order was instituted to monitor Resident #13's behaviors, including sexual behaviors. Behavior task monitoring was scheduled for once a shift and identified behaviors including walking slowly down the corridors, looking into other resident's rooms, lingering around female residents, and attempts at being sexually inappropriate. This monitoring documentation was to be completed through the Point of Care system (PCC) electronic medical record by the nurse assigned to care for the resident on the medication administration record and by the state tested nursing assistant (STNA) assigned to care for the resident on the task monitoring tool. • On [DATE] at 4:00 P.M., one-to-one monitoring of Resident #13's assigned direct care staff was initiated. The one-to-one included that Resident #13 was to have direct supervision 24- hours a day, seven days a week until further notice. A log sheet was implemented for staff to document when there was a change and what staff member was completing the one-to-one. Staff documented to have completed the one on one from [DATE] through [DATE] included STNA staff, the activity director and resident assistants (non-state tested care staff). • On [DATE] the facility-initiated auditing by the Interdisciplinary Team (IDT) to identify patterns or changes in behaviors of Resident #13. A plan for any identified patterns or behaviors would be addressed according to the findings. The facility Minimum Data Set 3.0 (MDS) nurses would update the plan of care accordingly and Unit Managers would be responsible for providing education to staff as changes are made. This audit was planned to remain in place until Resident #13 sustained a significant change and the threat to other residents was no longer valid. All oversight would be done by the Quality Assurance (QA) committee quarterly. • On [DATE] the facility adapted a new format to streamline investigations for more thorough, consistent investigations for each allegation of abuse. All 14 Registered Nurses (RNs) and 11 Licensed Practical Nurses (LPNs) were educated on the new policy/ procedure and paperwork by [DATE] by the DON or her designee. Oversight for ongoing training needs would be completed annually for skills training and as needed. All new employees would receive education on completing investigations by the DON or her designee upon hire. • On [DATE], Resident #13 was evaluated by Psychiatric Certified Nurse Practitioner (PCNP) #610 who documented Resident #13 had a history of sexual inappropriateness and secondary to the nature of the inappropriateness, the dosage of Lexapro (antidepressant) would be increased to 10 milligrams (mg) a day. PCNP #610 further documented the medication would take four to six weeks to determine effectiveness. • Beginning on [DATE], Resident #13's seating arrangements at meals and activities would be changed so that Resident #13 sat with only male residents. If the event was unavoidable, a staff member would be seated within reach of Resident #13 to prevent any physical touching of female residents. This was to be overseen by the DON or designee. • On [DATE] Resident #13 was started on the histamine medication, Cimetidine (Tagamet) as a medication used to decrease libido. • On [DATE] RN #544, RN #503 and RN #523 conducted observations of all residents with a Brief Interview for Mental Status score of 7 or less (indicative of cognitive impairment) including the 22 cognitively impaired female residents (Resident #1, #4, #8, #9, #12, #15, #19, #22, #26, #28, #32, #33, #34, #37, #38, #41, #45, #46, #50, #56, #59 and #60) for physical signs/symptoms of sexual abuse with no negative findings identified. • On [DATE] Assistant Director of Nursing (ADON) #519 conducted an audit of MDS data entries to determine if any facility residents had exhibited sexually inappropriate behavior in the past 30 days. Resident #13 was the only identified resident. • From [DATE] through [DATE] staff interviews completed with the following employees revealed they had received sexual abuse training and were aware of what to look for regarding resident to resident behaviors, how to complete thorough investigations, and Resident #13's specific behaviors: LPNs #505 and #513; RNs #514, #515 and #523; Dietary Aide (DA) #516 and #526; State Tested Nursing Assistants (STNAs) #507, #517, #518, #511 #524, #528, #530 and #542; Resident Assistant (RA) #520; Activities Director (AD) #521; Activities Assistant (AA) #522; Housekeepers (HSKP) #525, #527 and #532; Social Service (SS) #529; Therapy Manager (TM) #531 and Laundry Aide (LA) #533,. Although the Immediate Jeopardy was removed on [DATE] the facility remains out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Record review revealed Resident #13 was initially admitted to the facility on [DATE] with diagnoses including prostate cancer, Parkinson's disease, constipation, and muscle weakness. Record review revealed a plan of care, dated [DATE] which indicated Resident #13 had a history of sexually inappropriate behaviors with staff. The care plan was updated on [DATE] to reflect an incident in which Resident #13 tried to put the hand of a female resident down his pants. Interventions included to analyze key times of behaviors, staff members, places, circumstances, triggers, and what would de-escalate the behavior and document, assess and anticipate Resident #13's needs. The care plan indicated to complete a review of Resident #13's behaviors quarterly, inform Resident #13 his behaviors and/or comments were inappropriate and to stop. If the behaviors continued; make sure Resident #13 was safe and leave and return later with additional help. Additional interventions included monitor Resident #13's interactions daily, and notify the CNP or Physician of Resident #13's behaviors and ask them to reassess medications if the behaviors persisted. Review of Resident #13's quarterly MDS assessment, dated [DATE], revealed Resident #13 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The assessment revealed he exhibited physical behaviors directed towards others one to three days a week. Resident #13 was assessed to require limited assistance from one person for locomotion off the unit. On [DATE] record review revealed no documentation of a quarterly review of Resident #13's behaviors had been completed in 2018. Review of a facility self-reported incident (SRI), tracking number 153443, dated [DATE] revealed on [DATE] at 8:30 A.M. Laundry Supervisor (LS) #500 entered the room of female Resident #123 and saw Resident #13 at Resident #123's bedside. The SRI documented Resident #123's blanket was pulled down and Resident #13 had his hands close to the pelvic region of Resident #123. The SRI stated staff immediately intervened and removed Resident #13 from the room. The SRI documented the facility concluded the allegation of sexual abuse was unsubstantiated. Review of the facility incident investigation revealed a handwritten statement by LS #500 which stated on [DATE] around 8:30 A.M. LS #500 entered the room of Resident #123 and observed Resident #13 at the bedside of Resident #123. LS #500's written statement indicated Resident #123's blanket was removed, and Resident #13 had his hands between Resident #123's legs. LS #500 documented she left the room and told STNA #501 who immediately entered the room and removed Resident #13 from the room. Review of Resident #123's medical record revealed a lack of documentation including progress notes, assessments, or notification of the physician or family regarding the incident with Resident #13 on [DATE]. Review of Resident #13's medical record revealed a nursing progress note dated [DATE] at 12:59 P.M. written by RN #519 which indicated Resident #13 was spoken to regarding the inappropriateness of visiting female residents in their room unaccompanied. RN #519 further documented Resident #13 appeared uncomfortable, however stated understanding. RN #519 also documented the family was notified of the conversation as well. However, Resident #13's medical record contained no new assessments or behavioral referrals and the plan of care was not updated regarding the [DATE] incident or any new interventions to prevent further incidents of sexual abuse. Review of a facility incident report dated [DATE] at 7:45 A.M. and completed by RN #508 revealed STNA #501 had reported Resident #13 was observed in Resident #123's room with his hands in the vicinity of Resident #123's groin. The incident report did not include any documentation that a physical assessment of Resident #123 was completed. There was no documentation that Resident #123's responsible party or physician were notified of the incident or that any new interventions were implemented for Resident #13 at this time. Interview with LS #500 on [DATE] at 9:08 A.M. revealed on [DATE] at approximately 6:30 A.M. she was delivering laundry to residents' rooms. LS #500 reported she had initially seen Resident #13 go into Resident #123's room however she was not concerned. LS #500 then went into Resident #123's room to hang up clothing and heard a mumbling sound and turned around and saw Resident #13 with both hands, up to the wrist, under Resident #123's underwear making an up and down motion. LS #500 further stated she called out Resident #13's name and he jerked his hands back to where his hands were still under Resident #123's underwear. LS #500 said she ran into the hall and yelled for assistance. STNA #501 came to the room and told Resident #13 to stop and escorted Resident #13 from the room. LS #500 reported she had to write a statement regarding what she had observed but was told by the DON not to discuss the incident with anyone and it would be taken care of. LS #500 reported having been trained on abuse within the past month, however she said she was not trained on what to do in situations regarding resident to resident sexual abuse. LS #500 also repeatedly stated as a non-nursing employee, she had been told not to have physical contact with residents and to get assistance (from nursing staff) for any situations regarding residents. On [DATE] at 9:46 A.M. interview with STNA #501 revealed on [DATE] LS #500 had come into the hall asking for assistance. Upon entering the room of Resident #123, STNA #501 saw Resident #13 with his hands hovering approximately three to four inches above Resident #123's vaginal area. STNA #501 stated Resident #123's blanket was moved and did not cover the pelvic area. STNA #501 also stated she informed RN #508 of the incident, after escorting Resident #13 out of Resident #123's room. STNA #501 said she wrote a witness statement, however she had been interviewed by the DON before writing the statement. STNA #501 said the facility staff were trained at least yearly regarding abuse, however she had not received training specifically regarding what to do with residents with sexually inappropriate behaviors. STNA #501 stated Resident #13 was constantly touching his genitals. STNA #501 said there was no information in the kiosks, where the STNA staff find information on residents and resident tasks, directing staff to watch or monitor Resident #13 for any sexually oriented behaviors. STNA #501 said since she knew his history, she did watch Resident #13 more closely. Interview with the DON on [DATE] at 3:30 P.M. revealed the DON completed the facility investigation of the [DATE] incident. The DON confirmed a staff member witnessed Resident #13 touching Resident #123 inappropriately and went for help. The DON confirmed Resident #13 was no longer touching the resident when a second staff person, STNA #501, arrived. The DON also confirmed the SRI documented sexual abuse was unsubstantiated, but the DON was unable to remember why it was unsubstantiated. The DON confirmed the investigation did not include evidence Resident #123 was assessed for evidence of a sexual assault, was not sent to the hospital for evaluation and there was no evidence Resident #123's family or physician were notified of the incident. The DON confirmed the facility investigation lacked evidence that interviews were conducted with any other staff working at the time of the incident and there was insufficient evidence any facility residents in the area were interviewed as potential witnesses to this incident or had possibly experienced a similar incident. In addition, the investigation did not include a statement from Resident #13. The DON confirmed four facility residents were asked a general question about any concerns in the facility. The DON confirmed a thorough investigation was not completed. During a follow up interview on [DATE] at 7:30 A.M. the DON asked if an addendum could be added to the SRI. She said after review of the information again she said the allegation of sexual abuse involving Resident #13 and Resident #123 should have been substantiated. Review of Resident #123's closed medical record revealed Resident #123 was admitted to the facility [DATE] with diagnoses that included dementia without behavioral disturbances, hypertension, depressive disorder, dysphagia, psychosis and anxiety disorder. Review of the admission MDS, dated [DATE], revealed Resident #123 had severe cognitive impairment and required extensive assist of two staff for bed mobility, transfers, toileting, and personal hygiene. Review of an admission health status progress note, dated [DATE] at 3:00 P.M. by RN #508 revealed the resident was alert to self with confusion. There were no nursing progress notes documented between [DATE] and [DATE], the time of the sexual abuse. Resident #123 expired in the facility on [DATE]. Telephone interview with CNP #506 on [DATE] at 3:52 P.M. revealed she was not made aware of the incident of sexual abuse between Resident #13 and Resident #123. CNP #506 indicated she saw Resident #13 the day after the incident on [DATE]. CNP #506 indicated information for visits was gathered from the computer documentation system and stated at the time of her visit, no documentation regarding sexual abuse or sexually inappropriate behavior was noted. Review of a facility SRI revealed on [DATE] an incident of sexual abuse occurred between Resident #13 and another female resident, Resident #12. Review of Resident #12's medical record revealed an admission to the facility on [DATE] with diagnoses including Diabetes Mellitus, depression, chronic kidney disease, and unspecified dementia without behavioral disturbance. Review of Resident #12's quarterly MDS assessment, dated [DATE], revealed the resident was assessed to be severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of three. The assessment revealed the resident required an extensive assist of two persons for bed mobility and transfers and required extensive assist of one person for dressing, toilet use and personal hygiene. Review of Resident #12's plan of care dated [DATE] revealed the resident was at risk for injury related to several issues including dementia, impaired safety awareness, and impaired decision-making ability. Review of a facility SRI, tracking number 164683, dated [DATE] revealed Resident #12 had wandered into the doorway of Resident #13's room in her wheelchair. STNA #504 walked by the room and noted Resident #12 was sitting in the doorway. When STNA #504 went to remove Resident #12 from the doorway, Resident #13 was observed with his arm down Resident #12's blouse, up to his elbow. Resident #12 was removed from the location and Resident #13 was informed his behavior was inappropriate. The conclusion of the SRI revealed staff had been on high alert for female residents being around or in Resident #13's room and were to monitor what Resident #13 was doing at all times when he was out of his room. The SRI indicated Resident #13's son was notified, and the family was asked to address the behaviors with Resident #13. The DON spoke with Resident #13 and he did not recall the incident. A consult was made to psychological services. The facility substantiated an incident of sexual abuse with Resident #13 being the perpetrator. Review of Resident #13's medical record revealed no evidence of how or when the family addressed the behaviors with Resident #13. Review of the facility investigation for this incident revealed a written statement by STNA #504 dated [DATE] and signed on [DATE]. The statement verified the above information contained in the SRI. Interview with STNA #504 on [DATE] at 2:30 P.M. revealed on [DATE] between 3:00 P.M. and 4:00 P.M., she saw what she thought was another resident standing in the doorway over an unidentified resident. STNA #504 stated she then discovered Resident #12 in Resident #13's doorway. Resident #12 was in her wheelchair facing the inside of the room with her back to the hallway. Resident #13 was standing over the resident with his hand down the front of her blouse. STNA #504 stated she discovered Resident #13 with his hand all the way down her blouse to his elbow. STNA #504 described the incident in detail including Resident #13's hand and arm moving in an up and down motion under the blouse from the top of the chest to Resident #12's abdomen. STNA #504 stated she told Resident #13 to stop and he huffed at her and pulled his hand from the resident's blouse. STNA #504 described the huff as being upset because he was caught. STNA #504 stated she called for help, removed Resident #12 from Resident #13's room and told her supervisor what had happened. STNA #504 stated she was told to write a statement and give it to her supervisor. STNA #504 stated once she wrote the statement, that was the last she knew about the incident. STNA #504 stated she was not interviewed by the DON or her supervisor on what she had witnessed. STNA #504 said Resident #13 usually targeted residents who were more confused and could not call out for help or tell the resident no. STNA #504 stated she was not in-serviced on how to deal with Resident #13's inappropriate sexual behaviors. STNA #504 stated there was no information on the Kardex (a medical information system to communicate information about a resident) and she was not informed by nursing staff as to what types of behaviors to monitor for or report to the nurse. Review of Resident #12's nurse's notes dated [DATE] to [DATE] revealed no documented evidence the incident of sexual abuse/ inappropriate touch had taken place between Resident #13 and Resident #12. Resident #12's medical record contained no documented evidence she was assessed and evaluated for any type of injury. Review of Resident #13's medical record, following this incident revealed no nursing progress notes regarding the [DATE] incident with Resident #12. Resident #13's medical record revealed a Mini Mental Status Exam completed on [DATE] with a score of 23/30 which indicated mild cognitive impairment. Review of a psychiatry progress note, and evaluation completed on [DATE] revealed staff reported Resident #13 had a history of being sexually inappropriate and had incidents of sexual aggression towards female residents in the past. The evaluation documented that more recently, at the end of [DATE], Resident #13 was sexually aggressive towards a confused female patient and had been grabbling at her genitals and breasts. Resident #13 was placed on the anti-depressant medication Lexapro five milligrams (mg) every morning. Resident #13's care plan was updated to include the intervention of the psychiatry referral; however, it was not updated to include the sexual abuse incident from [DATE]. Phone interview with CNP #506 on [DATE] at 3:52 P.M. revealed she was not made aware of the incident of sexual abuse between Resident #12 and Resident #13. CNP #506 revealed she saw Resident #12 on [DATE] and was not informed of the incident on [DATE] prior to the visit. CNP #506 also stated she gathered information from the computer charting and there was no information documented regarding the incident. Interview on [DATE] at 7:15 A.M with LPN #505, the charge nurse on Resident #12's unit revealed she had heard through the rumor mill about an incident between Resident #13 and Resident #12. LPN #505 stated prior to the incident she had observed Resident #13 wandering in the halls and in the dining room. LPN #505 stated she was not told by the DON of any incidents between Resident #12 and Resident #13. LPN #505 verified neither Resident #12 or Resident #13's care plan had been changed to include increased monitoring. Interview with STNA #510 on [DATE] at 3:09 P.M. revealed there had been no training on how to deal with residents who had sexually inappropriate behaviors. STNA #510 stated Resident #13 needed to be observed more closely as he was ornery with women. STNA #510 stated she was made aware of this from another nurse and STNA involved in a prior incident. On [DATE] at 4:24 P.M., interview with the DON and the Administrator verified the above two documented incidents of sexual abuse involving Resident #13. The administrative staff verified there was no evidence the facility had developed and implemented a comprehensive and individualized behavior management plan to prevent Resident #13 from sexually abusing female residents in the facility. Interview with Medical Director (MD) #535 who was Resident #12, Resident #13, and Resident #123's primary care physician, on [DATE] at 8:37 A.M. revealed the facility had not notified him of any sexual abuse allegations or incidents in the facility, including the incidents involving Resident #13 on [DATE] and [DATE]. MD #535 also indicated sexual abuse had not been previously discussed during any of the facility quality assurance meetings held in 2018. Record review revealed one-to-one supervision was initiated for Resident #13 on [DATE] at 4:00 P.M. A memo for staff indicated the one-to-one supervision would be direct supervision 24 hours a day, seven days per week until further notice. It included training to ensure staff documented who was completing the one-to-one and indicated no agency staff could do the monitoring. On [DATE], Resident #13 was evaluated by Psychiatric CNP, PCNP #610 who documented Resident #13 had a history of sexual inappropriateness and secondary to the nature of the inappropriateness, the dosage of Lexapro would be increased to 10 milligrams (mg) a day. PCNP #610 further documented the medication would take four to six weeks to determine effectiveness. On [DATE] at 12:00 P.M. Resident #13 was observed in the dining room sitting at a table with Resident #15 (a female resident identified as being cognitively impaired) and two other residents. The closest staff member to Resident #13 was Resident Assistant, (RA) #520 who was sitting approximately twenty feet away from Resident #13. Interview with RA #520 on [DATE] at 12:18 P.M. revealed she was informed by the DON that she could sit far away from Resident #13 if she could monitor him. When RA #520 was questioned if she could redirect behaviors from twenty feet away and prevent inappropriate touching, RA #520 moved to Resident #13's left side. Review of Resident #13's medical record and behavior monitoring revealed on [DATE] at 10:59 A.M. Resident #13, while walking down the hall, unintentionally brushed his right hand against LPN #513's buttocks. Beginning on [DATE], a plan for Resident #13's seating arrangements at meals and activities would be changed so that Resident #13 sat with only male residents. If the event was unavoidable, a staff member would be seated within reach of Resident #13 to prevent any physical touching of female residents. During a follow up interview with the DON on [DATE] at 11:17 A.M. the DON revealed one-to-one supervision could only be sustained for Resident #13 for approximately six months. In lieu of one-to-one supervision, the DON indicated there were no other behavioral interventions or an individualized and comprehensive behavior management plan to prevent Resident #13 from sexually abusing other residents as of this time. Prior to the one-to-one supervision, Resident #13 had been started on the anti-depressant medication Lexapro (originally started on [DATE] and increased on [DATE]). Review of the medication usage with the DON and review of the MedScapes website indicated the side effect of Lexapro included a libido decrease of three to seven percent. Lexapro did not have an off-label usage for sexual libido decrease. The DON revealed on [DATE] she began a 30-day discharge process for Resident #13. No notice had been issued as of this time. On [DATE] a physician order was obtained for the medication, Cimetidine (Tagamet) prescribed once a day to decrease libido. Interview with CNP #611 on [DATE] at 7:26 A.M. revealed she had assessed and spoken to Resident #13 on this date. During the interview, the CNP indicated Resident #13 acknowledged he had been sexually inappropriate with female residents (specific names of residents and dates not provided) which she indicated constituted rape and that he appeared to be remorseful. The CNP had concerns with what the facility should or could do regarding Resident #13's sexually inappropriate behaviors. CNP #611 confirmed adding the medication Cimetidine (Tagamet) on [DATE], however stated the medication would take approximately three weeks to be noticeably effective. CNP #611 did confirm knowledge of Resident #13's history of sexually inappropriate behaviors and stated she had previously discussed interventions to be used with staff including telling Resident #13 when masturbating to conduct the act in the privacy of his room and to ask Resident #13 not to touch his penis in the shower. CNP #611 indicated she was unsure if these interventions had been or were being implemented by staff. During the interview the CNP indicated an interdisciplinary team approach with on-going monitoring, including the implementation of on-going psychological services and medication monitoring would be implemented to ensure Resident #13's sexually inappropriate behaviors were managed and to ensure the safety of the other facility residents. On [DATE] at 8:20 A.M. interview with the DON and Administrator revealed the administrative and nursing staff were actively working with Resident #13's physician and nurse practitioners to develop a long-term plan to address Resident #13's sexually inappropriate behaviors and that one-to-one supervision would be provided while evaluating the effectiveness of the new medications (Lexapro and Tagamet) that had been ordered. The DON indicated the need for one-to-one supervision would be re-evaluated as needed and indicated as part of the corrective action, all staff, not only nursing staff, were trained to identify sexually inappropriate behaviors and signs of sexual abuse. The Administrator also indicated the facility was actively evaluating whether Resident #13's needs could be met in this facility or if placement in a different facility would be needed to better meet the resident's needs. Review of facility policy titled, Abuse, Misappropriation Policy and Procedures updated [DATE], defined sexual abuse as including but not limited to sexual harassment, sexual coercion or sexual assault. Non-consensual sexual contact of any type with a resident was also defined as sexual abuse. The policy stated investigations would include, but were not limited to, interviews of the resi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility Self-Reported Incidents (SRIs), associated investigations and the facility abuse policy and procedure, interviews with staff, Medical Director #535, Certified Nurse Practitioner (CNP) #506 and #611 the facility failed to effectively implement their abuse policy and procedure to ensure Resident #12 and Resident #123, assessed as cognitively impaired, were free from sexual abuse by Resident #13. The facility also failed to ensure the incidents of sexual abuse were thoroughly investigated. This resulted in Immediate Jeopardy and the potential for serious harm on [DATE] at 6:30 A.M. when Resident #13 was observed in Resident #123's room with his hands inside Resident #123's underwear. The Immediate Jeopardy remained ongoing, on [DATE] at 8:15 P.M. when Resident #13 was observed with his arm/hand down the front of Resident #12's blouse. There was no evidence, following either incident, the facility immediately assessed Resident #123 or Resident #12 and no evidence the facility implemented interventions to prevent further incidents of sexual abuse by Resident #13. In addition, the facility failed to effectively implement their Abuse policy and procedure to ensure incidents of verbal/emotional abuse involving Residents #29, #320 and #321 identified during review of the SRIs dated [DATE], [DATE] and [DATE] were thoroughly investigated. . This affected two residents for sexual abuse (Residents #12 and #123) and three residents for verbal abuse (Resident #29, #320 and #321.). The facility identified 21 additional cognitively impaired female residents (Residents #1, #4, #8, #9, #15, #19, #22, #26, #28, #32, #33, #34, #37, #38, #41, #45, #46, #50, #56, #59 and #60) as at risk for sexual abuse due to a lack of investigation. The facility census was 70. On [DATE] at 4:24 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when Resident #13 was observed with his hands inside Resident #123's underwear making sexual motions. The Immediate Jeopardy continued on [DATE] when Resident #13 was observed with his arm down the front of Resident #12's blouse. The facility failed to thoroughly investigate either incident of sexual abuse and failed to timely develop and implement an individualized plan for Resident #13 to address sexually inappropriate behaviors and prevent additional incidents of sexual abuse. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE], the DON initiated education for all staff members on sexual abuse, safety of residents during a potentially abusive situation, resident rights, how to report suspected abuse and who to report it to. The training was overseen by the Administrator. As of [DATE] at 8:40 A.M., 174 of 179 staff members were in-serviced. The five staff members who had not received the education were on leave and a plan for these employees to receive the education prior to returning to work was in place. • On [DATE], the facility implemented a plan for behavior monitoring to be completed each shift per the charge nurse for Resident #13. The charge nurse would audit for verbal or physical sexual advances, initiate interventions including redirection to supervised activities or to his room, one on one supervision or medication administration to deter or stop behavior and determine the effectiveness. This would remain ongoing until Resident #13 had a significant change in condition which the facility had defined as a functional decline related to Parkinson's disease. This will be overseen by the Quality Assurance (QA) committee quarterly. • On [DATE] Resident #13's plan of care was updated to reflect the addition of Lexapro for sexually inappropriate behaviors and to reflect his past incidents of sexual abuse with female the residents. • On [DATE] the facility Abuse policy and procedure was updated to include definitions of potential sources of abuse including resident to resident, staff to resident, family member to resident, and visitor to resident. • On [DATE] a physician's order was instituted to monitor Resident #13's behaviors, including sexual behaviors. Behavior task monitoring was scheduled for once a shift and identified behaviors including walking slowly down the corridors, looking into other resident's rooms, lingering around female residents, and attempts at being sexually inappropriate. This monitoring documentation was to be completed through the Point of Care system (PCC) electronic medical record by the nurse assigned to care for the resident on the medication administration record and by the State tested nursing assistant (STNA) assigned to care for the resident on the task monitoring tool. • On [DATE] at 4:00 P.M., one-to-one monitoring of Resident #13 assigned/scheduled direct care staff was initiated. The one-to-one included that Resident #13 was to have direct supervision 24- hours a day, seven days a week until further notice. A log sheet was implemented for staff to document when there was a change and what staff member was completing the one-to-one. Staff documented to have completed the one on one from [DATE] through [DATE] included STNA staff, the activity director and resident assistants (non-State tested care staff). • On [DATE] the facility-initiated auditing by the Interdisciplinary Team (IDT) to identify patterns or changes in behaviors of Resident #13. A plan for any identified patterns or behaviors would be addressed according to the findings. The facility Minimum Data Set 3.0 (MDS) nurses would update the plan of care accordingly and Unit Managers would be responsible for providing education to staff as changes are made. This audit was planned to remain in place until Resident #13 sustained a significant change and the threat to other residents was no longer valid. All oversight would be done by the Quality Assurance (QA) committee quarterly. • On [DATE] the facility adapted a new format to streamline investigations for more thorough, consistent investigations for each allegation of abuse. The new investigation policy now included step by step procedures the investigation should take, including a potential of witnesses, general questions to ask for residents and witnesses, documents checklist, investigation log, and investigation summary form. All 14 Registered Nurses and 11 Licensed Practical Nurses were educated on the new policy/ procedure and paperwork by [DATE] by the DON or her designee. Oversight for ongoing training needs would be completed annually for skills training and as needed. All new employees would receive education on completing investigations by the DON or her designee upon hire. • On [DATE], Resident #13 was evaluated by Psychiatric Certified Nurse Practitioner (PCNP) #610 who documented Resident #13 had a history of sexual inappropriateness and secondary to the nature of the inappropriateness, the dosage of Lexapro (antidepressant) would be increased to 10 milligrams (mg) a day. PCNP #610 further documented the medication would take four to six weeks to determine effectiveness. • Beginning on [DATE], Resident #13's seating arrangements at meals and activities would be changed so that Resident #13 sat with only male residents. If the event was unavoidable, a staff member would be seated within reach of Resident #13 to prevent any physical touching of female residents. This was to be overseen by the DON or designee. • On [DATE] Resident #13 was started on the histamine medication, Cimetidine (Tagamet) as a medication used to decrease libido. • On [DATE] RN #544, RN #503 and RN #523 conducted observations of all residents with a Brief Interview for Mental Status score of 7 or less (indicative of cognitive impairment) including the 22 cognitively impaired female residents (Resident #1, #4, #8, #9, #12, #15, #19, #22, #26, #28, #32, #33, #34, #37, #38, #41, #45, #46, #50, #56, #59 and #60) for physical signs/symptoms of sexual abuse with no negative findings identified. • On [DATE] Assistant Director of Nursing (ADON) #519 conducted an audit of MDS data entries to determine if any facility residents had exhibited sexually inappropriate behavior in the past 30 days. Resident #13 was the only identified resident. • From [DATE] through [DATE] staff interviews completed with the following employees revealed they had received sexual abuse training and were aware of what to look for regarding resident to resident behaviors, how to complete thorough investigations, and Resident #13's specific behaviors: LPNs #505 and #513, RNs #514, #515 and #523, Dietary Aide (DA) #516 and #526 State Tested Nursing Assistants (STNAs) #507, #517, #518, #511 #524, #528, #530 and #542, Resident Assistant (RA) #520, Activities Director (AD) #521, Activities Assistant (AA) #522, Housekeepers (HSKP) #525, #527 and #532, Social Service (SS) #529, Therapy Manager (TM) #531 and Laundry Aide (LA) #533,. Although the Immediate Jeopardy was removed on [DATE] the facility remains out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Record review revealed Resident #13 was initially admitted to the facility on [DATE] with diagnoses including prostate cancer, Parkinson's disease, constipation, and muscle weakness. Record review revealed a plan of care, dated [DATE] which indicated Resident #13 had a history of sexually inappropriate behaviors with staff. The care plan was updated on [DATE] to reflect an incident in which Resident #13 tried to put the hand of a female resident down his pants. Interventions included to analyze key times, staff members, places, circumstances, triggers, and what would de-escalate the behavior and document, assess and anticipate Resident #13's needs. The care plan indicated to complete a review of Resident #13's behaviors quarterly, inform Resident #13 his behaviors and/or comments were inappropriate and to stop. If the behaviors continued to make sure resident #13 was safe and to leave and return later with additional help. Additional interventions included to monitor Resident #13's interactions daily, and to notify the CNP or Physician of Resident #13's behaviors and ask them to reassess medications if behaviors persist. Record review revealed no documentation of a quarterly review of Resident #13's behaviors had been completed in 2018. Review of a facility self-reported incident (SRI), tracking number 153443, dated [DATE] revealed on [DATE] at 8:30 A.M. Laundry Supervisor (LS) #500 entered the room of female Resident #123 and saw Resident #13 at Resident #123's bedside. The SRI documented Resident #123's blanket was pulled down and Resident #13 had his hands close to the pelvic region of Resident #123. The SRI stated staff immediately intervened and removed Resident #13 from the room. The SRI documented the facility concluded the allegation of sexual abuse was unsubstantiated. Review of the facility incident investigation revealed a handwritten statement by LS #500 which stated on [DATE] around 8:30 A.M. LS #500 entered the room of Resident #123 and observed Resident #13 at the bedside of Resident #123. LS #500's written statement indicated Resident #123's blanket was removed, and Resident #13 had his hands between Resident #123's legs. LS #500 documented she left the room and told STNA #501 who immediately entered the room and removed Resident #13 from the room. Review of Resident #123's medical record revealed a lack of documentation including progress notes, assessments, or notification of the physician or family regarding the incident with Resident #13 on [DATE]. Review of Resident #13's medical record revealed a nursing progress note dated [DATE] at 12:59 P.M. written by RN #519 which indicated Resident #13 was spoken to regarding the inappropriateness of visiting female residents in their room unaccompanied. RN #519 further documented Resident #13 appeared uncomfortable, however stated understanding. RN #519 also documented the family was notified of the conversation as well. However, Resident #13's medical record contained no new assessments or behavioral referrals and the plan of care was not updated regarding the [DATE] incident or any new interventions to prevent further incidents of sexual abuse. Review of a facility incident report dated [DATE] at 7:45 A.M. and completed by RN #508 revealed STNA #501 had reported Resident #13 was observed in Resident #123's room with his hands in the vicinity of Resident #123's groin. The incident report did not include any documentation that a physical assessment of Resident #123 was completed. There was no documentation that Resident #123's responsible party or physician were notified of the incident or that any new interventions were implemented for Resident #13 at this time. Interview with LS #500 on [DATE] at 9:08 A.M. revealed on [DATE] at approximately 6:30 A.M. she was delivering laundry to residents' rooms. LS #500 reported she had initially seen Resident #13 go into Resident #123's room however she was not concerned. LS #500 then went into Resident #123's room to hang up clothing and heard a mumbling sound and turned around and saw Resident #13 with both hands, up to the wrist, under Resident #123's underwear making an up and down motion. LS #500 further stated she called out Resident #13's name and he jerked his hands back to where his hands were still under Resident #123's underwear. LS #500 said she ran into the hall and yelled for assistance. STNA #501 came to the room and told Resident #13 to stop and escorted Resident #13 from the room. LS #500 reported she had to write a statement regarding what she had observed but was told by the DON not to discuss the incident with anyone and it would be taken care of. LS #500 reported having been trained on abuse within the past month, however she said she was not trained on what to do in situations regarding resident to resident sexual abuse. LS #500 also repeatedly stated as a non-nursing employee, she had been told not to have physical contact with residents and to get assistance (from nursing staff) for any situations regarding residents. On [DATE] at 9:46 A.M. interview with STNA #501 revealed on [DATE] LS #500 had come into the hall asking for assistance. Upon entering the room of Resident #123, STNA #501 saw Resident #13 with his hands hovering approximately three to four inches above Resident #123's vaginal area. STNA #501 stated Resident #123's blanket was moved and did not cover the pelvic area. STNA #501 also stated she informed RN #508 of the incident, after escorting Resident #13 out of Resident #123's room. STNA #501 said she wrote a witness statement, however she had been interviewed by the DON before writing the statement. STNA #501 said the facility staff were trained at least yearly regarding abuse, however she had not received training specifically regarding what to do with residents with sexually inappropriate behaviors. STNA #501 stated Resident #13 was constantly touching his genitals. STNA #501 said there was no information in the kiosks, where the STNA staff find information on residents and resident task, directing staff to watch or monitor Resident #13 for any sexually oriented behaviors. STNA #501 said since she knew his history, she did watch Resident #13 more closely. Interview with the DON on [DATE] at 3:30 P.M. revealed the DON completed the facility investigation of the [DATE] incident. The DON confirmed a staff member witnessed Resident #13 touching Resident #123 inappropriately and went for help. The DON confirmed Resident #13 was no longer touching the resident when a second staff person, STNA #501, arrived. The DON also confirmed the SRI documented sexual abuse was unsubstantiated, but the DON was unable to remember why it was unsubstantiated. The DON confirmed the investigation did not include evidence Resident #123 was assessed for evidence of a sexual assault, was not sent to the hospital for evaluation and there was no evidence Resident #123's family or physician were notified of the incident. The DON confirmed the facility investigation lacked evidence that interviews were conducted with any other staff working at the time of the incident and there was insufficient evidence any facility residents in the area were interviewed as potential witnesses to this incident or who possibly experienced a similar incident. In addition, the investigation did not include a statement from Resident #13. The DON confirmed four facility residents were asked a general question about any concerns in the facility. The DON confirmed a thorough investigation was not completed. During a follow up interview on [DATE] at 7:30 A.M. the DON asked if an addendum could be added to the SRI. She said after review of the information again she said the allegation of sexual abuse involving Resident #13 and Resident #123 should have been substantiated. Review of Resident #123's closed medical record revealed Resident #123 was admitted to the facility [DATE] with diagnoses that included dementia without behavioral disturbances, hypertension, depressive disorder, dysphagia, psychosis and anxiety disorder. Review of the admission MDS, dated [DATE], revealed Resident #123 had severe cognitive impairment and required extensive assist of two staff for bed mobility, transfers, toileting, and personal hygiene. Review of an admission health status progress note, dated [DATE] at 3:00 P.M. by RN #508 revealed the resident was alert to self with confusion. There were no nursing progress notes documented between [DATE] and [DATE], the time of the sexual abuse. Resident #123 expired in the facility on [DATE]. Review of a facility SRI revealed on [DATE] an incident of sexual abuse occurred between Resident #13 and another female resident, Resident #12. Review of Resident #12's medical record revealed an admission to the facility on [DATE] with diagnoses including Diabetes Mellitus, depression, chronic kidney disease, and unspecified dementia without behavioral disturbance. Review of Resident #12's quarterly MDS assessment, dated [DATE], revealed the resident was assessed to be severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of three. The assessment revealed the resident required an extensive assist of two persons for bed mobility and transfers and required extensive assist of one person for dressing, toilet use and personal hygiene. Review of Resident #12's plan of care dated [DATE] revealed the resident was at risk for injury related to several issues including dementia, impaired safety awareness, and impaired decision-making ability. Review of a facility SRI, tracking number 164683, dated [DATE] revealed Resident #12 had wandered into the doorway of Resident #13's room in her wheelchair. STNA #504 walked by the room and noted Resident #12 was sitting in the doorway. When STNA #504 went to remove Resident #12 from the doorway, Resident #13 was observed with his arm down Resident #12's blouse, up to his elbow. Resident #12 was removed from the location and Resident #13 was informed his behavior was inappropriate. The conclusion of the SRI revealed staff had been on high alert for female residents being around or in Resident #13's room and were to monitor what Resident #13 was doing at all times when he was out of his room. The SRI indicated Resident #13's son was notified, and the family was asked to address the behaviors with Resident #13. The DON spoke with Resident #13 and he did not recall the incident. A consult was made to psychological services. The facility substantiated an incident of sexual abuse with Resident #13 being the perpetrator. Review of Resident #13's medical record revealed no evidence of how or when the family addressed the behaviors with Resident #13. Review of the facility investigation for this incident revealed a written statement by STNA #504 dated [DATE] and signed on [DATE]. The statement verified the above information contained in the SRI. Interview with STNA #504 on [DATE] at 2:30 P.M. revealed on [DATE] between 3:00 P.M. and 4:00 P.M., she saw what she thought was another resident standing in the doorway over an unidentified resident. STNA #504 stated she then discovered Resident #12 in Resident #13's doorway. Resident #12 was in her wheelchair facing the inside of the room with her back to the hallway. Resident #13 was standing over the resident with his hand down the front of her blouse. STNA #504 stated she discovered Resident #13 with his hand all the way down her blouse to his elbow. STNA #504 described the incident in detail including Resident #13's hand and arm moving in an up and down motion under the blouse from the top of the chest to Resident #12's abdomen. STNA #504 stated she told Resident #13 to stop and he huffed at her and pulled his hand from the resident's blouse. STNA #504 stated she called for help, removed Resident #12 from Resident #13's room and told her supervisor what had happened. STNA #504 stated she was told to write a statement and give it to her supervisor. STNA #504 stated once she wrote the statement, that was the last she knew about the incident. STNA #504 stated she was not interviewed by the DON or her supervisor on what she had witnessed. STNA #504 stated she was not in-serviced on how to deal with Resident #13's inappropriate sexual behaviors. STNA #504 stated there was no information on the Kardex (a medical information system to communicate information about a resident) and she was not informed by nursing staff as to what types of behaviors to monitor for or report to the nurse. Review of Resident #12's nurse's notes dated [DATE] to [DATE] revealed no documented evidence the incident of sexual abuse/ inappropriate touch had taken place between Resident #13 and Resident #12. Resident #12's medical record contained no documented evidence she was assessed and evaluated for any type of injury. Review of Resident #13's medical record, following this incident revealed no nursing progress notes regarding the [DATE] incident with Resident #12. Resident #13's medical record revealed a Mini Mental Status Exam completed on [DATE] with a score of 23/30 which indicated mild cognitive impairment. Review of a psychiatry progress note, and evaluation completed on [DATE] revealed staff reported Resident #13 had a history of being sexually inappropriate and had incidents of sexual aggression towards female residents in the past. The evaluation documented that more recently, at the end of [DATE], Resident #13 was sexually aggressive towards a confused female patient and had been grabbling at her genitals and breasts. Resident #13 was placed on the anti-depressant medication Lexapro five milligrams (mg) every morning. Resident #13's care plan was updated to include the intervention of the psychiatry referral; however, it was not updated to include the sexual abuse incident from [DATE]. Phone interview with CNP #506 on [DATE] at 3:52 P.M. revealed she was not made aware of the incident of sexual abuse between Resident #12 and Resident #13. CNP #506 revealed she saw Resident #12 on [DATE] and was not informed of the incident on [DATE] prior to the visit. CNP #506 also stated she gathered information from the computer charting and there was no information documented regarding the incident. Interview on [DATE] at 7:15 A.M with LPN #505, the charge nurse on Resident #12's unit revealed she had heard through the rumor mill about an incident between Resident #13 and Resident #12. LPN #505 stated prior to the incident she had observed Resident #13 wandering in the halls and in the dining room. LPN #505 stated she was not told by the DON of any incidents between Resident #12 and Resident #13. LPN #505 verified neither Resident #12 or Resident #13's care plan had been changed to include increased monitoring. Interview with STNA #510 on [DATE] at 3:09 P.M. revealed there had been no training on how to deal with residents who had sexually inappropriate behaviors. STNA #510 stated Resident #13 needed to be observed more closely as he was ornery with women. STNA #510 stated she was made aware of this from another nurse and STNA involved in a prior incident. On [DATE] at 4:24 P.M., interview with the DON and the Administrator verified the above two documented incidents of sexual abuse involving Resident #13. The administrative staff verified there was no evidence the facility had developed and implemented a comprehensive and individualized behavior management plan to prevent Resident #13 from sexually abusing female residents in the facility. Interview with Medical Director (MD) #535 who was Resident #12, Resident #13, and Resident #123's primary care physician, on [DATE] at 8:37 A.M. revealed the facility had not notified him of any sexual abuse allegations or incidents in the facility, including the incidents involving Resident #13 on [DATE] and [DATE]. MD #535 also indicated sexual abuse had not been previously discussed during any of the facility quality assurance meetings held in 2018. Interview with CNP #611 on [DATE] at 7:26 A.M. revealed she had assessed and spoken to Resident #13 on this date. During the interview, the CNP indicated Resident #13 acknowledged he had been sexually inappropriate with female residents (specific names of residents and dates not provided) which she indicated constituted rape and that he appeared to be remorseful. The CNP had concerns with what the facility should or could do regarding Resident #13's sexually inappropriate behaviors. CNP #611 confirmed adding the medication Cimetidine (Tagamet) on [DATE], however stated the medication would take approximately three weeks to be noticeably effective. CNP #611 did confirm knowledge of Resident #13's history of sexually inappropriate behaviors and stated she had previously discussed interventions to be used with staff including telling Resident #13 when masturbating to conduct the act in the privacy of his room and to ask Resident #13 not to touch his penis in the shower. CNP #611 indicated she was unsure if these interventions had been or were being implemented by staff. During the interview the CNP indicated an interdisciplinary team approach with on-going monitoring, including the implementation of on-going psychological services and medication monitoring would be implemented to ensure Resident #13's sexually inappropriate behaviors were managed and to ensure the safety of the other facility residents. On [DATE] at 8:20 A.M. interview with the DON and Administrator revealed the administrative and nursing staff were actively working with Resident #13's physician and nurse practitioners to develop a long-term plan to address Resident #13's sexually inappropriate behaviors and that one-to-one supervision would be provided while evaluating the effectiveness of the new medications (Lexapro and Tagamet) that had been ordered. The DON indicated the need for one-to-one supervision would be re-evaluated as needed and indicated as part of the corrective action, all staff, not only nursing staff, were trained to identify sexually inappropriate behaviors and signs of sexual abuse. The Administrator also indicated the facility was actively evaluating whether Resident #13's needs could be met in this facility or if placement in a different facility would be needed to better meet the resident's needs. Review of facility policy titled, Abuse, Misappropriation Policy and Procedures updated [DATE], defined sexual abuse as including but not limited to sexual harassment, sexual coercion or sexual assault. Non-consensual sexual contact of any type with a resident was also defined as sexual abuse. The policy stated investigations would include, but were not limited to, interviews of the resident, resident's roommate, interview of staff currently working and those that had worked previously; working backwards until no further information could be obtained or the cause had been revealed. The policy also stated other entities would be notified depending on the situation including local law enforcement. The policy did not address the notification of resident's responsible parties. 2. Review of a facility SRI, tracking number 154913 dated [DATE] revealed Resident #320 alleged a facility STNA did not take her to the restroom as requested, instead informed Resident #320 she had already been there. The facility concluded an allegation of verbal/emotional abuse was unsubstantiated. Review of the investigation of the allegation revealed the facility completed an interview with Resident #320, interviewed the STNA involved, received a written statement from the STNA involved and three other staff members, and reviewed the call light log from the 11 - 7 shift on [DATE]. The conclusion of the facility investigation was to do staff education with the STNA involved regarding urinary frequency in the geriatric population and the types of signs and symptoms to report to the nurse. Further review into the facility investigation revealed the facility did not interview any other residents regarding care received or treatment from staff during the investigation. Interview with the DON on [DATE] at 3:30 P.M. confirmed the facility investigation lacked thorough interviews with staff working at the time of the incident and no additional facility residents in the area were interviewed as potential witnesses to this incident or possibly experienced a similar incident. The DON confirmed the lack of evidence did not support a thorough investigation was completed. Review of facility policy titled, Abuse, Misappropriation Policy and Procedures updated [DATE], defined verbal/emotional abuse as oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families. The policy stated investigations would include, but were not limited to, interviews of the resident, resident's roommate, interview of staff currently working and those that had worked previous working backwards until no further information could be obtained or the cause had been revealed. The policy also stated other entities would be notified depending on the situation including local law enforcement. 3. Review of facility SRI, tracking number 161549 dated [DATE] revealed Resident #29 alleged a facility STNA had called her a name. The facility concluded an allegation of verbal/emotional abuse was unsubstantiated. Review of the investigation into the allegation revealed the facility completed an interview with Resident #29, interviewed the STNA involved, and received written statements from two staff members whom Resident #29 had discussed her concerns with. Further review into the facility investigation revealed the facility did not interview any other residents regarding care received or treatment from staff during the investigation. Interview with the DON on [DATE] at 3:30 P.M. confirmed the facility investigation lacked thorough interviews with staff working at the time of the incident and no additi[TRUNCATED]

Based on record review, review of two facility Self-Reported Incidents (SRIs), associated investigations and the facility abuse policy and procedure, interviews with staff, Medical Director #535 and Certified Nurse Practitioner (CNP) #506 the facility failed to ensure incidents of sexual abuse, involving Resident #12 and Resident #123, assessed as cognitively impaired, were thoroughly investigated. This resulted in Immediate Jeopardy and the potential for serious harm on 05/06/18 at 6:30 A.M. when Resident #13 was observed in Resident #123's room with his hands inside Resident #123's underwear. The Immediate Jeopardy remained ongoing, on 11/27/18 at 8:15 P.M. when Resident #13 was observed with his arm/hand down the front of Resident #12's blouse. There was no evidence, following either incident, the facility conducted thorough investigations of the alleged sexual abuse. In addition, the facility failed to ensure incidents of verbal/emotional abuse involving Residents #29, #320 and #321 identified during review of the SRIs dated 06/01/18, 09/28/18 and 09/30/18 were thoroughly investigated. . This affected two residents for sexual abuse (Residents #12 and #123) and three residents for verbal abuse (Resident #29, #320 and #321.). The facility identified 21 additional cognitively impaired female residents (Residents #1, #4, #8, #9, #15, #19, #22, #26, #28, #32, #33, #34, #37, #38, #41, #45, #46, #50, #56, #59 and #60) as at risk for sexual abuse due to a lack of investigation. The facility census was 70. On 12/11/18 at 4:24 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 05/06/18 when Resident #13 was observed with his hands inside Resident #123's underwear making sexual motions. The Immediate Jeopardy continued on 11/27/18 when Resident #13 was observed with his arm down the front of Resident #12's blouse. The facility failed to thoroughly investigate either incident of sexual abuse and failed to timely develop and implement an individualized plan for Resident #13 to address sexually inappropriate behaviors and to prevent additional incidents of sexual abuse. The Immediate Jeopardy was removed on 12/17/18 when the facility implemented the following corrective actions: • On 12/11/18, the DON initiated education for all staff members on sexual abuse, safety of residents during a potentially abusive situation, resident rights, how to report suspected abuse and who to report it to. The training was overseen by the Administrator. As of 12/14/18 at 8:40 A.M., 174 of 179 staff members were in-serviced. The five staff members who had not received the education were on leave and a plan for these employees to receive the education prior to returning to work was in place. • The facility Abuse policy and procedure was updated to include definitions of potential sources of abuse on 12/12/18, these include resident to resident, staff to resident, family member to resident, and visitor to resident. • On 12/13/18 the facility adapted a new format to streamline investigations for more thorough, consistent investigations for each allegation of abuse. The new investigation policy now included step by step procedures the investigation should take, including a potential of witnesses, general questions to ask for residents and witnesses, documents checklist, investigation log, and investigation summary form. All 14 Registered Nurses (RN) and 11 Licensed Practical Nurses (LPN) were educated on the new policy/ procedure and paperwork by 12/14/18 by the DON or her designee. Oversight for ongoing training needs would be completed annually for skills training and as needed. All new employees would receive education on completing investigations by the DON or her designee upon hire. • From 12/12/18 through 12/17/18 staff interviews completed with the following employees revealed they had received sexual abuse training and were aware of what to look for regarding resident to resident behaviors, how to complete thorough investigations, and Resident #13's specific behaviors: LPNs #505 and #513; RNs #514, #515 and #523; Dietary Aide (DA) #516 and #526; State Tested Nursing Assistants (STNAs) #507, #517, #518, #511 #524, #528, #530 and #542; Resident Assistant (RA) #520; Activities Director (AD) #521; Activities Assistant (AA) #522; Housekeepers (HSKP) #525, #527 and #532; Social Service (SS) #529; Therapy Manager (TM) #531 and Laundry Aide (LA) #533,. Although the Immediate Jeopardy was removed on 12/17/18 the facility remains out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of a facility self-reported incident (SRI), tracking number 153443, dated 05/06/18 revealed on 05/06/18 at 8:30 A.M. Laundry Supervisor (LS) #500 entered the room of female Resident #123 and saw Resident #13 at Resident #123's bedside. The SRI documented Resident #123's blanket was pulled down and Resident #13 had his hands close to the pelvic region of Resident #123. The SRI stated staff immediately intervened and removed Resident #13 from the room. The SRI documented the facility concluded the allegation of sexual abuse was unsubstantiated. Review of the facility incident investigation revealed a handwritten statement by LS #500 which stated on 05/06/18 around 8:30 A.M. LS #500 entered the room of Resident #123 and observed Resident #13 at the bedside of Resident #123. LS #500's written statement indicated Resident #123's blanket was removed, and Resident #13 had his hands between Resident #123's legs. LS #500 documented she left the room and told STNA #501 who immediately entered the room and removed Resident #13 from the room. Review of Resident #123's medical record revealed a lack of documentation including progress notes, assessments, or notification of the physician or family regarding the incident with Resident #13 on 05/06/18. Review of Resident #13's medical record revealed a nursing progress note dated 05/07/18 at 12:59 P.M. written by RN #519 which indicated Resident #13 was spoken to regarding the inappropriateness of visiting female residents in their room unaccompanied. RN #519 further documented Resident #13 appeared uncomfortable, however stated understanding. RN #519 also documented the family was notified of the conversation as well. Review of a facility incident report dated 05/06/18 at 7:45 A.M. and completed by Registered Nurse (RN) #508 revealed STNA #501 had reported Resident #13 was observed in Resident #123's room with his hands in the vicinity of Resident #123's groin. The incident report did not include any documentation that a physical assessment of Resident #123 was completed. There was no documentation that Resident #123's responsible party or physician were notified of the incident or that any new interventions were implemented for Resident #13. Interview with the DON on 12/10/18 at 3:30 P.M. revealed the DON completed the facility investigation of the 05/06/18 incident. The DON confirmed a staff member witnessed Resident #13 touching Resident #123 inappropriately and went for help. The DON confirmed Resident #13 was no longer touching the resident when a second staff person, STNA #501, arrived. The DON also confirmed the SRI documented sexual abuse was unsubstantiated, but the DON was unable to remember why it was unsubstantiated. The DON confirmed the investigation did not include evidence Resident #123 was assessed for evidence of a sexual assault, was not sent to the hospital for evaluation and there was no evidence Resident #123's family or physician were notified of the incident. The DON confirmed the facility investigation lacked evidence that interviews were conducted with any other staff working at the time of the incident and there was insufficient evidence any facility residents in the area were interviewed as potential witnesses to the incident or may have experienced a similar incident. In addition, the investigation did not include a statement from Resident #13. The DON confirmed four facility residents were asked a general question about any concerns in the facility. The DON confirmed a thorough investigation was not completed. During a follow up interview on 12/11/18 at 7:30 A.M. the DON asked if an addendum could be added to the SRI. She said after review of the information again she said the allegation of sexual abuse involving Resident #13 and Resident #123 should have been substantiated. Telephone interview with Certified Nurse Practitioner (CNP) #506 on 12/11/18 at 3:52 P.M. revealed she was not made aware of the incident of sexual abuse between Resident #13 and Resident #123. CNP #506 indicated she saw Resident #13 the day after the incident on 05/07/18. CNP #506 indicated information for visits was gathered from the computer documentation system and stated at the time of her visit, no documentation regarding sexual abuse or sexually inappropriate behavior was noted. On 11/28/18 review of a facility Self-Reported Incident revealed another incident of sexual abuse occurred between Resident #13 and another female resident, Resident #12. Review of a facility SRI, tracking number 164683, dated 11/28/18 revealed Resident #12 had wandered into the doorway of Resident #13's room in her wheelchair. STNA #504 walked by the room and noted Resident #12 was sitting in the doorway. When STNA #504 went to remove Resident #12 from the doorway, Resident #13 was observed with his arm down Resident #12's blouse, up to his elbow. Resident #12 was removed from the location and Resident #13 was informed his behavior was inappropriate. The conclusion of the SRI revealed staff had been on high alert for female residents being around or in Resident #13's room and to were to monitor what Resident #13 was doing at all times when he was out of his room. The SRI indicated Resident #13's son was notified, and the family was asked to address the behaviors with Resident #13. The DON spoke with Resident #13 and he did not recall the incident. A consult was made to psychological services. The facility substantiated an incident of sexual abuse with Resident #13 being the perpetrator. Review of Resident #13's medical record revealed no evidence of how or when the family addressed the behaviors with Resident #13. Review of the facility investigation for this incident revealed a written statement by STNA #504 dated 11/27/18 and signed on 11/29/18. This statement verified the above information contained in the SRI. Phone interview with Certified Nurse Practitioner (CNP) #506 on 12/11/18 at 3:52 P.M. revealed she was not made aware of the incident of sexual abuse between Resident #12 and Resident #13. CNP #506 revealed she saw Resident #12 on 12/10/18 and was not informed of the incident on 11/26/18 prior to the visit. CNP #506 also stated she gathered information from the computer charting and there was no information documented regarding the incident. Interview with Medical Director (MD) #535 who was Resident #12, Resident #13, and Resident #123's primary care physician, on 12/13/18 at 8:37 A.M. revealed the facility had not notified him of any sexual abuse allegations or incidents in the facility, including the incidents involving Resident #13 on 05/06/18 and 11/27/18. MD #535 also indicated sexual abuse had not been previously discussed during any of the facility quality assurance meetings held in 2018. During a follow up interview with the DON on 12/16/18 at 11:17 A.M. the DON verified the concerns related to the lack of documentation regarding the SRIs completed involving Resident #13, lack of thorough investigation and lack of documentation of family and physician notification. Review of facility policy titled, Abuse, Misappropriation Policy and Procedures updated November 2016, revealed investigations would include, but were not limited to, interviews of the resident, resident's roommate, interview of staff currently working and those that had worked previously; working backwards until no further information could be obtained or the cause had been revealed. The policy also stated other entities would be notified depending on the situation including local law enforcement. The policy did not address the notification of resident's responsible parties. 2. Review of a facility SRI, tracking number 154913 dated 06/01/18 revealed Resident #320 alleged a facility STNA did not take her to the restroom as requested, instead informed Resident #320 she had already been there. The facility concluded an allegation of verbal/emotional abuse was unsubstantiated. Review of the investigation of the allegation revealed the facility completed an interview with Resident #320, interviewed the STNA involved, received a written statement from the STNA involved and three other staff members, and reviewed the call light log from the 11 - 7 shift on 05/31/18. The conclusion of the facility investigation was to do staff education with the STNA involved regarding urinary frequency in the geriatric population and the types of signs and symptoms to report to the nurse. Further review into the facility investigation revealed the facility did not interview any other residents regarding care received or treatment from staff during the investigation. Interview with the DON on 12/10/18 at 3:30 P.M. confirmed the facility investigation lacked thorough interviews with staff working at the time of the incident and no additional facility residents in the area were interviewed as potential witnesses to this incident or possibly experienced a similar incident. The DON confirmed the lack of evidence did not support a thorough investigation was completed. 3. Review of facility SRI, tracking number 161549 dated 09/28/18 revealed Resident #29 alleged a facility STNA had called her a name. The facility concluded an allegation of verbal/emotional abuse was unsubstantiated. Review of the investigation into the allegation revealed the facility completed an interview with Resident #29, interviewed the STNA involved, and received written statements from two staff members whom Resident #29 had discussed her concerns with. Further review into the facility investigation revealed the facility did not interview any other residents regarding care received or treatment from staff during the investigation. Interview with the DON on 12/10/18 at 3:30 P.M. confirmed the facility investigation lacked thorough interviews with staff working at the time of the incident and no additional facility residents in the area were interviewed as potential witnesses to this incident or possibly experienced a similar incident. The DON confirmed the lack of evidence did not support a thorough investigation was completed. 4. Review of facility SRI, tracking number 161630 dated 09/30/18 revealed Resident #321 alleged an STNA was gruff and rough during personal care. The facility concluded an allegation of verbal/emotional abuse was unsubstantiated. Review of the investigation into the allegation revealed the facility completed an interview with Resident #321 and her daughter, interviewed the STNA involved, and received a written statement from the STNA involved and two other staff members, one of whom was a witness. Further review into the facility investigation revealed the facility did not interview any other residents regarding care received or treatment from staff during the investigation. Interview with the DON on 12/10/18 at 3:30 P.M. confirmed the facility investigation lacked thorough interviews with staff working at the time of the incident and no additional facility residents in the area were interviewed as potential witnesses to this incident or possibly experienced a similar incident. The DON confirmed the lack of evidence did not support a thorough investigation was completed.